Healthcare Provider Details

I. General information

NPI: 1417492034
Provider Name (Legal Business Name): MARINA SHORES OB/GYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2017
Last Update Date: 03/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2865 LYNNHAVEN DR SUITE 4A
VIRGINIA BEACH VA
23451-1542
US

IV. Provider business mailing address

2865 LYNNHAVEN DR SUITE 4A
VIRGINIA BEACH VA
23451-1542
US

V. Phone/Fax

Practice location:
  • Phone: 757-496-5000
  • Fax:
Mailing address:
  • Phone: 757-496-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101256943
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0101256943
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number0101256943
License Number StateVA

VIII. Authorized Official

Name: DR. LANI MARIE WARREN
Title or Position: OB/GYN PHYSICIAN
Credential: MD
Phone: 757-496-5000